Triple vessel disease

1. CLERKSHIPASSESSMENT -III
DEPARTMENT : CARDIOLOGY
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2. DEMOGRAPHIC DETAILS :
NAME : XYZ AGE : 67 years D.O.A:10/07/17
SEX : M DEPT : CARDIOLOGY D.O.D: 14/07/17
CHIEF COMPLAINTS :
c/o left sided chest pain ; since 3days
increased pain since 8:00 am associated with sweating,pain radiating to left
hand
PAST MEDICAL HISTORY : since 5 years
HTN ( on TELMISARTAN 20mg)
T2 DM (on metformin 500mg)
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3. GENERAL EXMANINATION :
o/e pt c/c
temp : afebrile
SYSTEMIC EXAMINATION :
BP : 150/100 mm Hg PR : 64 /min
RESP : BAE+ CVS : S1+S2+
PROVISIONAL DIAGNOSIS: CAD -ACUTE INFEROPOSTERIOR
MYOCARDIAL INFARCTION
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4. SYMPTOMATIC TREATMENT
1.Tab. ASPIRIN 325mg stat PO antiplatelet
2.Tab.TICAGRELOR 180mg stat PO antiplatelet
3.Tab.ATORVASTATIN 40mg OD PO hypolipidemic
4.Inj.HEPARIN 5000IU TID IV anticoagulant
5.Inj.NITROGLYCERIN 0.3ml/hr(each ml contain 5mg)
6.Inj.NS 1 pint 50ml/hr
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5. LABORATORY INVESTIGATIONS :
Hb - 12g% (N : 12-18g%)
Blood urea – 54 mg/dl (N : 10-50mg/dl)
serum creatinine - 1.8 mg/dl (N: 0.5-1.5mg/dl)
Troponin .T - 0.31ng/ml (N : <0.03ng/ml)
2D ECHO : Inferoposterior wall hypokinetic,Moderate left ventricular
dysfuncion,LVEF(40%),CAD
CORONARY ANGIOGRAM : Triple vessel disease
FINAL DIAGNOSIS : CAD /TRIPLE VESSEL DISEASE
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6. On 11/07/17
Advice : PCI with stent to Posterior Descending Artery(PDA),Left Circumflex
Artery, Posterior Left Ventricular Artery(PLV)
FOLLOW UP :
o/e pt c/c
temp: N BP:160/90mmHg
P/A : soft CVS : S1+S2+
TREATMENT :
1. Tab. ASPIRIN 75mg PO OD
2. Tab. TICAGRELOR 90mg PO BD
3. Tab.ROSUVASTATIN 40mg PO OD
4. Inj. HEPARIN 5000IU IV QID
5. Tab. NEFROSAVE 150/500mg PO BD
6. Inj.NTG @0.3ml/hr IV
7. Inj.CEFAZOLINE 1g IV TID
8. Inj. NS 1pint IV 50ml/hr
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7. On 12/07/17
pt c/c
BP: 140/80mm Hg CVS :S1+S2+
PR : 67/min RS : BAE+
TREATMENT : continue same treatment
add : tab. CILNIDIPINE 10mg PO OD
tab. NITROGLYCERINE SR 2.6mg PO BD
Inj. PANTOPRAZOLE 40mg IV OD
On 13/07/17
pt c/c
c/o restlessness
BP : 130/90mmHg CVS : S1+S2+
PR : 81/min
advice : stop Inj.NTG
add tab.ALPRAZOLAM 0.25mg sos
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8. CORONARY ARTERY DISEASE( TRIPLE VESSEL DISEASE)
 Heart muscle is supplied with three major coronary arteries i.e.,left anterior
descending,left circumflex,right coronary artery.
 In posterior wall myocardial infarction the major artery assosiated is right
coronary artery and its branch (postetior descending artery)
 Acute coronary syndrome includes Unstable angina,NSTE MI,STE MI.
 The cause is erosion or rupture of an atherosclerotic plaque with subsequent
platelet adherence.
 Patients who smoke, or having diabetes or HTN and with high blood
cholesterols are more prone to CAD .
 The obstruction of oxygen rich blood flow to myocardial cells leads to
necrosis and may lead to heart failure.
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9. GOALS OF THERAPY :
Pain management (with nitroglycerin 3 doses,if not releived then with
morphine)
Prevention of death.
Maintenance of blood volume/tissue perfusion(with normal saline or dextran)
Prevention and treatment of arrythmias(with i.v .beta blockers)
Prevention of future attacks
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10. STANDARD TREATMENT :(ACC/AHA Guidelines)
 Oxygen inhalation ( if oxygen saturation is <90%)
 Aspirin (160-325mg)
 sublingual NTG (0.4 mg every 5min for 3 doses)
 High risk patients(as per TIMI score) should proceed to early coronary
angiography)
 Anticoagulant(UFH/ enaxoparin / fondaparinux) to patients with NSTE ACS
undergoing PCI to reduce risk of intracoronary and catheter thrombus formation.
 I.V beta blockers (if not contraindicated) and I.V Nitroglycerine( to patients with
persistent ischemia or heart faliure or hypertension) should be given to selected
patients.
 I.V Nitroglycerin (5-10mcg/min titrated upto 75-100mcg/min until relief of
symptoms)
 In patients with NSTE ACS continuing or frequently recurring ischemia and a
contraindication to beta blocker a non dihyropyridine CCB(verapamil ,
diltiazem)should be given as initial therapy(to relieve coronary artery spasm)
 Fibrionlytic therapy is indiacted in STE MI but is not in any patient with NSTE
ACS.Because risks of fibrinolytic therapy(bleeding overweigh the benifit for NSTE
ACS patients)
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11.  According to TIMI score and GRACE score high risk patients should undergo early
angiography (within 12 to 24 hrs) and revascularization ( with percutaneous
coronary intervention/CABG) if significant coronary artery stenosis is found.
 Moderate risk patients with positive biochemical markers for infarction also will
undergo angiography and revascularization.
 Patients undergoing PCI should take 325mg aspirin before PCI and a loading dose
of P2Y12 receptor inhibiotors given before procedure in patients undergoing PCI
with stenting : clopidogrel 600mg or
prasugrel 60mg or Ticagrelor180mg
DUALANTIPLATELET THERAPY(DAPT)
 In patients with ACS ,treat with DAPT after stent implantation,P2Y12 inhibitor
therapy( clopidogrel/prasugrel/ticagrelor)should be given for atleast 12 months
 In Patients with DAPT ,daily aspirin dose of 81mg(range 75mg to 100mg) is
recommended
 After stent implantation it is reasonable to use ticagrelor in preferrable to
clopidogrel.
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12.  An ACE inhibitor should be started within 24hrs of presentation particularly
if LVEF <40% and in those with HTN/ DM/CKD.
 High intensity statin therapy should be initiated or continued in all patients
with ACS and no contraindications to its use.
 As per guidelines ,after an ACS all patients should recieve DAPT therapy
ideally for 12months followed by lifelong aspirin therapy.
GOALS ACHEIVED :
 Reduction of signs and symptoms
 Reperfusion done with stent implantation in three vessels.
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13. INTERVENTION :
 Aspirin plus Heparin leads to increased risk of bleeding. Before administration
of Heparin, aPTT should be monitored and the dose should be adjusted based
on the aPTT. Regular monitoring of aPTT is necessary when patient is on
Heparin.
 short acting Dihydropyridine calcium channel blockers (clinidipine)
contraindiacted in this case. (according to ACC guidelines)
DRUG -DRUG INTERACTION:
 Atorvastatin +pantoprazole increases side effects of atorvastatin by increased
levels of atorvastatin in blood.Increased risk of musculoskeletal
toxicity.Therapy should be discontinued if Creatinine kinase is markedly
elevated.
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14. DISCHARGE MEDICATION :
 Tab.ASPIRIN 75mg OD
 Tab.TICAGRELOR 90mg OD
 Tab.ATORVASTATIN 40mg OD
 Tab. CLINIDIPINE 10mg OD
 Tab. NITROGLYCERINE 2.6mg BD
 Tab.PANTOPRAZOLE 40mg OD
 Tab. ALPRAZOLAM 0.25mg SOS
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15. PATIENT COUNSELLING :
 Dont stop aspirin on your own. As it is life saving. It may be a life long therapy
 Take atorvastatin at night after meals.
 Nitroglycerine tablet may cause hypotension.Dont drive or operate machines
while on nitroglycerine. If u feel lightheadedness or any hypotensive features
immediately report to physician. It is potentially fatal when taken with alcohol.
 Take alprazolam at nights,when u feel restlessness(not more than one dose).
 Control major risk factors (Diabetes, smoking,cholesterol,HTN)
 Regularly use Antihypertensives and hypoglycemic agents.
 control your HTN by reducing intake of sodium to not more than
2400mg/day,moderate alcohol consumption,low fat intake,limitation of saturated
and trans fat,regular exercise,body weight control(as per JNC 8 guidelines).
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16. PRESENTED BY
K.ARUN
PHARM.D V YEAR
13371D1009
VAAGDEVI INSTITUTE OF PHARMACEUTICAL SCIENCES
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